American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, August 20, 2014

Lifestyle medicine and the parable of the tiny parachute

A commentary was published on the blog site of the prestigious British Medical Journal telling us, in essence, that lifestyle medicine is ineffective. Specifically, it said that screening for chronic disease risk factors in the general population, and addressing them with lifestyle counseling in the clinical setting, is of no value.

The commentary was in response to a paper published in the BMJ that reached essentially the same conclusion. An accompanying editorial was entitled: “General health checks don’t work“ and began with “it’s time to let them go.”

The trial that provoked these responses randomized a large sample of Danish adults either to screening for chronic disease risk factors with tailored lifestyle counseling, or usual care. After 10 years, the 2 groups did not differ for the rate of heart disease or all-cause mortality.

One additional tidbit is worth noting, and a tidbit it is. The “intervention” consisted of three individualized lifestyle counseling sessions of 15 to 45 minutes each, spread over the first 3 years of the 10-year study period. If you will, the intervention was itself a tidbit of lifestyle counseling. Additional 6-group sessions were available, but that means even for the rare participants who took advantage of all offerings, less than 1 counseling session per year of observation. The sessions were made available to those study participants with overt chronic disease risk factors, including smoking, high alcohol intake, poor diet, and/or lack of physical activity.

I can’t help but initiate my reaction to all this with a rhetorical question: would anyone actually expect that between 45 minutes and 2 hours of clinical counseling over 3 years would meaningfully change health outcomes over 10 years for people who potentially smoke, drink, eat badly and avoid exercise?

To say the least, I would not. In fact, I would sum all this up metaphorically with the parable of the tiny parachute.

Imagine that the utility of parachutes was as yet unproven, and the task of proving their worth falls to us. We design an experiment accordingly. Parachutes are attached to—well, we can go with wine bottles; or ceramic eggs; or real eggs for that matter; or people if we are feeling brave—and these objects are tossed out of airplanes. A remote control device deploys the parachutes and we land to ascertain what we’ve wrought.

We find a mass of broken glass and splintered eggshells. Let’s hope we didn’t involve any live volunteers, or we would also find a jumble of mangled bodies. And so it is proven that parachutes are useless.

But we know that isn’t true. What if our parachutes were ridiculously tiny, each the size of a postage stamp? Or what if they were opened too late, each deployed within mere inches of the ground? Or maybe they were both too little and too late.

In that case, our experiment actually tells us nothing about the value of parachutes. It simply tells us that too little is too little, and too late is too late.

And so it is with lifestyle medicine. Of course it works, when it’s good medicine, timely, and dosed appropriately. The parable of the tiny parachute reveals that what might in fact be a highly effective intervention done right can be an entirely useless intervention done wrong. We are mostly doing it wrong.

For one thing, we are working against a monumental force. In the case of the parachute, the monumental force is gravity. A parachute works, of course, but even at its best, it only slows our fall rather than stopping it. A pervasive, relentless force wins against even good interventions.

In the case of obesity and chronic disease, that force pervades our culture; or more bluntly, it is our culture. Schedules that preclude time and attention to health until there is virtually no good choice left; a food supply willfully adulterated to strip away nutritional value and maximize the calories it takes to feel full; an ever greater variety of labor saving technologies; and so on. Worst of all is the hypocrisy of a culture that frets about the health of its children, but nonetheless sanctions the aggressive peddling to them of multicolored marshmallows and the like, calling such junk “part of a complete breakfast,” adding to the blatant, epidemiologic injury an insult to our intelligence.

The power of lifestyle medicine is best revealed where lifestyle is working as medicine throughout the expanse of culture, rather than delivered in medicine as an antidote to cultural misdeeds. The world’s Blue Zones exemplify this. The longest-lived, healthiest, happiest people on the planet do not attribute these blessings to high quality clinical counseling; they attribute them to a culture that puts health on the path of lesser resistance, and to prevailing norms.

That said, high quality clinical counseling can make a difference, and is most needed where culture is least salutary. But it must be high quality counseling, and most of what is provided by non-experts falls well short of that bar.

Models exist that adapt the best behavior modification techniques into the primary care setting; my colleagues and I have developed one such, available for free. Intensive skill-building programs can do far more to help people lose weight and find health than a few sessions with a clinician spread over years. And when the problem is advanced, such as severe obesity in teens, the evidence favors truly immersive therapy to offer an adequate dose of the lifestyle remedy.

Clinicians can and should play an important role in delivering lifestyle as medicine. For that to happen, the standards of such counseling, and affiliated programming, need to rise. I am privileged to serve at present as President of the American College of Lifestyle Medicine, an organization devoted both to this proposition, and to the propagation of programs that empower clinicians to provide better help, and empower patients to put good guidance to better use. We have an exciting conference coming up in the fall, so please click here if interested in learning more. We have sister organizations around the world, helping us turn lifestyle medicine into the global movement it should be.

Good clinical counseling can function like a good parachute; it can make a meaningful difference. We simply don’t see such benefit when we do too little, too late.

We can, however, do even better than the best of parachutes. We can never eliminate the downward pull of gravity; we can only resist it. But we can reverse the downward drag of culture on our collective health. We can use clinics to provide customized guidance toward better health, but we could also use our culture to put health for all on a path of lesser resistance. I have elaborated the details of what I think that effort would entail on a number of prior occasions, and invite the action-oriented to see them here, and here, and here, and here and here.

For everyone else, the parable will suffice. Of course parachutes work, but only when they are good parachutes.

When we administer lifestyle medicine effectively not just in clinics, but throughout our culture, we can do even better than slow our fall. We can climb.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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